Govt to probe aged care facility after death

The coronial findings given exclusively to Lateline by the Brumby family, reveal shocking neglect and flagrant disregard for the principle that old people deserve a safe and comfortable place to spend out their days.

Transcript

Producer: Brett Evans.

TONY JONES, PRESENTER: Dulcie Brumby was one of Australia's last traditional nomads, a leader of her Pitjantjatjara community.

A year ago the 72-year-old dementia sufferer died after accidentally falling into a fire at the Docker River aged care home, around 300km from Uluru.

The coronial findings found routine neglect at home where Dulcie Brumby was fatally burnt.

Well Lateline's story has sparked a major overhaul of the standards that apply to these special Indigenous nursing homes, and a new inquiry has Dulcie Brumby's death.

Suzanne Smith compiled this had special report. And a warning: Indigenous viewers are advised this story contains images and names of people who have died.

(Sound of singing).

SUZANNE SMITH: For the Pitjantjatjara people of the central deserts, fire fulfils a spiritual and physical need.

Today, Kevin Brumby is making a barbecued lunch of kangaroo tails for his family, and his lawyer Neil Bell.

Neil Bell used to be the local member for this area, the seat of MacDonnell in the Northern Territory. He had a special connection to Kevin's mother, Dulcie Brumby, who he first met in 1975 when he was a teacher at the community of Areyonga.

NEIL BELL, LAWYER: Dulcie regarded our children as hers and we vice versa, we've tried to fulfil some obligations in that regard.

SUZANNE SMITH: Dulcie Brumby was a young girl before she met her first white person. This photograph of Dulcie and her brother was taken some time in the 1940s.

She led a traditional nomadic life until the Lutheran missionaries convinced her family to settle at Areyonga.

In the late 1960s Dulcie and her family came to live permanently at Docker River as part of a government supported resettlement program.

MARK SWINDELLS, YOUTH AFFAIRS, MISSION AUSTRALIA: Dulcie was one of the last nomads. They're few and far between; and, you know, they're national icons, they're real treasures. And we have to recognise these people are quickly disappearing.

SUZANNE SMITH: Youth worker Mark Swindells first met Dulcie Brumby in 1995. The same year the Docker River aged care facility opened to great fanfare, the first of its kind in Australia.

(Sound of singing).

In the beginning, it was well run and much loved by the old people.

REPORTER (ABC News 1995): In central Australia's cross border region Aboriginal old people are afraid of being sent away to aged care homes, often dying hundreds of kilometres from their family and land.

SUZANNE SMITH: 12 years later, by the time Dulcie Brumby was in her 70s, the Docker River home had already developed serious problems.

It was the evening of June 14, 2007, 1 week before the federal intervention that Dulcie Brumby would die in terrible circumstances.

The coronial findings into her death by Deputy Coroner Celia Kemp have been obtained by 'Lateline'.

It was a bitterly cold night, and the old people were sitting around the fire pits that are built into the verandas of the home.

They were unsupervised as the home did not provide staff to care for the patients from six at night until six in the morning. High and low risk patients have no overnight supervision.

The Deputy Coroner believes that Dulcie Brumby fell into one of these fire pits her in the aged care home.

She then staggered alight in flames, walked down here, past her own bedroom, and travelled here into the open air into this back garden area.

It was then that she staggered, very dazed, to the back of her own bedroom.

It was at this moment that Mark Swindells was leaving the carers cottage at the back of the aged care facility. He noticed a bright fire.

MARK SWINDELLS: It was quite a horrific scene, actually. I suppose the best way to describe it is the old black and white photo. I think of a monk in Vietnam who was protesting about the political situation at the time and who doused himself in petrol and burnt himself.

So that image comes to... back to me. But she was walking at the time, she wasn't sitting down. And yeah...

SUZANNE SMITH: She was engulfed in flames?

MARK SWINDELLS: Yes, she was. I think she was... just starting to sort of go out, but she'd had a parker on. It was a beautiful, sort of, ski parker, down filled.

It was a little bit surreal actually, because it was down floating throughout the air. But being a ski parker I don't think it was designed to be fire proof.

Mark Swindells ran to Dulcie Brumby and pushed her to the ground smothering the flames with his own coat.

MARK SWINDELLS: She was extremely confused; she was making noises. And when I actually got off her and took my jacket off her, to my horror she stood back up again and started walking around.

SUZANNE SMITH: Mark Swindells believes it took about half an hour before the ambulance arrived to take Dulcie Brumby to the clinic. Where she finally got pain relief. Normally it is a three minute walk.

MARK SWINDELLS: If I hadn't probably extinguished her then she probably would've perished quicker which probably would've been the nicest thing. I know that's unusual thing to say, but, you know, the tragedy at the end of the day was how long it actually took her to pass away, because she was not gonna survive it.

SUZANNE SMITH: The Docker River airstrip cannot be used at night, so Dulcie Brumby had to be transported to another airport 150km away.

The Deputy Coroner's report says it took nearly nine hours before Dulcie Brumby reached Alice Springs hospital for treatment at seven in the morning. She died a long way from home, five hours later.

The Deputy Coroner Celia Kemp's findings are very critical.

"It seems clear that the deceased needed a much greater level of care than the Docker River Aged Care Centre could provide."

And "It is clear that the risk of deceased burning herself during the long unsupervised night hours, was high, and predictable."

However, the Deputy Coroner does not recommend an inquest. She writes:

"I note that the Aged Care Centre towards having overnight staff: They are converting an office into a bed sitter and the recruitment had started as of Friday 8 June 2007."

"This will enable them to take care of higher needs clients. I am therefore not making any recommendations in this case".

More than one year later and there are still no overnight staff.

This aged care facility at Docker River is one of 39 special Indigenous homes across the country.

And while it doesn't have to meet the stringent accreditation standards of other homes across Australia, it must be a safe place free from risk.

Dulcie Brumby's death raises serious questions about how the Commonwealth Government could've funded this facility for so long, despite the fact there was no overnight supervision of patients.

Lilian Jeter is the satellite executive director of the Elder Abuse Prevention Association.

LILIAN JETER: Why was there not a staff member there, or staff members? I mean this is a residential care facility.

They had high level care residents there as well as low level care. Not to have a staff member present is absolutely horrible, it's deplorable.

SUZANNE SMITH: Ms Jeter says the facility receives around $800,000 in funding a year and be subject to auditing and spot checks.

And Lateline can reveal that the Commonwealth Department of Health was alerted, as early as 2005, about the facilities poor standards, when it received a major complaint by a community development consultant who visited the aged care home.

Maggie Kavanagh writes:

"Over a one week period I witnessed large amounts of rubbish throughout the grounds, the constant presence of large numbers of dogs (up to 10). Most distressing was that I observed that the residents did not look well cared for and many had a stench of urine on them."

"I also observed two other staff members who I considered to be stoned on duty in the middle of the day."

Maggie Kavanagh met with Commonwealth officials in May 2005. She showed them several photos, including this one of broken pavings in the facility, which was responsible for one resident tripping over and breaking her hip.

Lawyer Neil Bell has now sent a letter to the Northern Territory Deputy Coroner requestioning she immediately order a public inquest to take into account the new information about the death.

NEIL BELL: The synthetic garments, the lack of overnight supervision, and the time for evacuation are three issues that... that are important facts within the meaning of the coroner's Act.

SUZANNE SMITH: Deputy Coroner Dr Celia Kemp has released statement saying she feels a public inquest into the death would not take the matter any further.

Michael Gravener has just been appointed manager of the facility by the MacDonnell Shire.

MICHAEL GRAVENER: The staffing issue is a concern, and it's already been looked at. It will be looked at thoroughly, as far as resources and the type of people that we're looking after.

I would always judge it if my mother was alive, if it was suitable for her, and so if it is good enough for her, it's good enough for anyone. So that's the sort of standard we should maintain.

SUZANNE SMITH: Is anyone overnight at the moment?

MICHAEL GRAVENER: No, we have a situation where there is a duress alarm and staff who live just on... or off site in the community housing, they're very close, they react to, if anyone rings that bell, and they come and see what the situation is.

SUZANNE SMITH: At least two bed ridden patients have had to rely on other patients to ring the duress button to get help.

Michael Gravener says he is now recruiting extra staff for the aged care home. But he says there needs to be much greater accountability.

MICHAEL GRAVENER: People in my position have to be responsible so that no more Dulcie's die such a tragic death.

The culture of remote service giving being lesser than any other organisation, well, that's got to stop.

SUZANNE SMITH: Kevin Brumby pays as visit to the graves of his brothers and mother at Docker River cemetery.